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Hawaii’s health marketplace

How hard is Hawaii fighting to preserve the Affordable Care Act’s provisions? Compare to other states’ efforts.

After two years of using a technologically troubled state-based enrollment system, Hawaii began using the HealthCare.gov enrollment platform for the 2016 open enrollment period. In November 2016, Hawaii switched to a federally run exchange, although that state still oversees the plans that are sold in the exchange.

Hawaii’s exchange has two insurers that offer individual market coverage for 2020. Average full-price premiums are decreasing in Hawaii’s individual market for 2020, for the first time since ACA-compliant plans debuted. Rates increased sharply in 2016, 2017, and 2018, but only grew by about 5 percent in 2019 and are now declining by about 4 percent for 2020, bringing the weighted average back to just slightly higher than it was in 2018.

20,193 people enrolled in 2019 coverage through Hawaii’s exchange during open enrollment. Hawaii is one of just a few states where enrollment in the exchange has grown every year since 2014.

Medicaid expansion in Hawaii

A total of 328,713 people – about 23 percent of Hawaii’s population – were enrolled in Medicaid/CHIP in Hawaii as of August 2019. About 118,500 people had gained coverage in the state by 2017 as a result of Medicaid expansion (in states that expanded Medicaid in 2014, enrollment growth had largely leveled out by 2016/2017).

Medicaid expansion has certainly benefited low-income Hawaii residents, particularly those with low or no employment and no access to the employer-based health insurance that most Hawaii residents enjoy.

How did Obamacare help Hawaii?

Hawaii has long supported broad access to medical insurance. The state’s historically low uninsured rate is largely the result of the Hawaii Prepaid Health Care Act, which was enacted in 1974 and requires most employers to provide health insurance to employees who work more than 20 hours a week.

The Hawaii Prepaid Health Care Act has much stronger requirements for employer-provided coverage than the ACA. Hawaii’s 1332 waiver to eliminate the SHOP exchange (which was the first 1332 waiver approved in the nation) was a direct result of the state’s success under the Hawaii Prepaid Health Care Act .

According to U.S. Census data, Hawaii’s uninsured rate was 6.7 percent in 2013 (far lower than the national average of 14.5 percent), and had fallen to 4 percent by 2015 (again, less than half the national average of 9.4 percent by that point). It was a little higher by 2017 and 2018, at 5 percent, mirroring the nationwide trend of increasing uninsured rates under the Trump administration.

Many states had much more significant drops in their uninsured rates, but they also started with a much higher percentage of the population without health insurance in 2013. As of 2018, only Massachusetts, Vermont, and the District of Columbia had lower uninsured rates than Hawaii; the national average uninsured rate at that point was 8.9 percent.

Hawaii Medicare enrollment

By late 2019, Hawaii Medicare enrollment reached 274,739 people – about 19 percent of the state’s population, which is just a little higher than the percentage of the U.S. population enrolled in Medicare.

Hawaii has the smallest percentage of Medicare recipients who are on Medicare as the result of a disability:just 9 percent. The other 91 percent of recipients qualify for Hawaii Medicare based on age alone.

As of 2017, per-beneficiary Medicare spending in Hawaii was $ $7,0421 – the lowest in the nation. (The national average was $9,761.)

Hawaii Medicare beneficiaries can select a Medicare Advantage plan instead of Original Medicare if they want to gain some additional benefits and don’t mind the provider network restrictions that go along with private Medicare coverage. About 46 percent of Hawaii Medicare recipients selected a Medicare Advantage plan.

Medicare Part D plans are also available to Hawaii Medicare beneficiaries who want stand-alone prescription drug coverage. As of late 2019, there were 72,104 Hawaii Medicare beneficiaries who had a stand-alone Rx plan. Another 123,001 had Medicare Advantage plans that included integrated Part D coverage.

Transitional (grandmothered) health plans in Hawaii

Transitional (grandmothered) health plans are those that took effect after the ACA was signed into law in March 2010, but before the bulk of its provisions went into effect in 2014. These plans were initially slated to terminate at the end of 2013 or at their renewal dates in 2014, but a series of federal extensions have allowed them to continue to renew, at each state’s discretion.

As recently as the regulation they published in 2018 (which allowed transitional plans to extend through the end of 2019), Hawaii was going along with the federal extensions, allowing transitional plans in both the individual and small group markets to remain in force .

But the state’s extension for 2020 only applies to small group plans. Although individual market transitional plans were allowed to remain in force in Hawaii in 2019, HMSA opted to terminate all of their individual market transitional plans at the end of 2018 (see SERFF filing HMSA-131977825; the insurer clarifies that about two-thirds of their transitional plan enrollees subsequently enrolled in ACA-compliant HMSA plans for 2019).

Hawaii health insurance resources

State-level health reform in Hawaii

In July 2017, Governor Ige signed S.B.513 into law, joining states like New York and Oregon that have taken steps to protect and even enhance the contraceptive benefits that the ACA conferred.

Hawaii partially addressed this issue many years ago, when the state required all state-regulated employer-sponsored health plans to cover the full range of FDA-approved contraceptives, starting in 2000 (the initial impacts of this change are discussed here).

Hawaii’s new law, which took effect immediately, allows pharmacists to dispense up to 12 months of contraceptives, even if the patient does not have a prescription from a physician. The pharmacist must have the patient complete a “self-screening risk assessment tool” and refer the patient to a primary care physician, but must also provide the contraceptives regardless of whether the patient follows through on the referral.

Hawaii law, along with the ACA, requires health plans to cover contraceptives, but S.B.513 extends the coverage to include reimbursement for pharmacists who prescribe and dispense contraceptives.

During the legislative session, H.B.513 received widespread support, but also some opposition. The Hawaii section of the American College of Obstetricians and Gynecologists (ACOG) opposed the legislation because they felt that it didn’t go far enough in terms of expanding access to contraceptives. ACOG felt that birth control should be available over-the-counter, and that even requiring a visit with a pharmacist was too restrictive.

Hawaii enacted legislation in 2017 that created a working group that was tasked with making recommendations for codifying ACA protections into state law. In 2018, acting on the recommendations of the working group, Hawaii enacted legislation that prohibits gender rating, pre-existing condition exclusions, and application denials based on medical history. The legislation also protects parents’ ability to keep their children on their health plan until age 26.